25259 Kinross Buffer Fence - LEIN Request.pdf
PDF 165 KB Posted
- Solicitation number
- RFQ 171 250000000618 2
- Issued by
- Chippewa County, Michigan
About this file
This is a LEIN (Michigan Law Enforcement Information Network) Request Form CAJ-1037, Revision 09/19, issued by the Michigan Department of Corrections (MDOC) for the Kinross Correctional Facility Buffer Fence & Entrance Gate project (File #472/25259.ABG). The form is designed to collect personal information and authorization for criminal history background checks required for individuals entering the secure perimeter or property of an MDOC facility to perform work, visit, or conduct business related to the project. Required information includes the applicant's full name, date of birth, address, sex, race, and identification number (either driver's license or state ID). The form specifies that individuals must be cleared through the LEIN system before being permitted access to secure areas of the correctional facility.
The LEIN request form includes an authorization section allowing MDOC to conduct criminal history checks and, for MDOC HR/Employment purposes only, to verify motor vehicle operator license records. The form provides space for indicating the number of convictions and optional comments. Completion of the LEIN background check is mandatory for all contractors, visitors, volunteers, and HR personnel accessing MDOC facilities. The form must be signed and dated by the individual requesting access, and subsequently completed and cleared by designated MDOC personnel. This document represents a standard security and compliance requirement rather than a procurement solicitation or contract award notification.
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Text version
MICHIGAN DEPARTMENT OF CORRECTIONS
LEIN REQUEST
CAJ-1037.
REV. 09/19.
Please provide the information requested below. This information will be used to complete a criminal history check in the Michigan Law Enforcement Information Network (LEIN).
Your Driver’s License Number or State Identification Card Number, date-of-birth, race and sex is needed to complete this LEIN request.
Employment/Human Resources HR Personnel / Requesting
Contractor Visitor Contractor Agency Agency Representing
Volunteer Other Agency Representing Agency Representing Are you entering the secure perimeter/property of a Michigan Department of Corrections (MDOC) facility? Yes No
Please print information below:
Last Name: First Name: Middle Name:
Address:
City: State: Zip Code:
Date of Birth: Sex: Race:
Please provide the number of one of the following types of identification:
Driver’s License #: State issued by:
State ID #: State issued by:
I authorize the MDOC to conduct a criminal history check, so that I may be approved to enter the secure perimeter/property of an MDOC facility to perform work, visit, meet with or work with MDOC offenders.
For MDOC HR/Employment purposes only: I further authorize the Department to check my motor vehicle operator license record for the purposes of determining if I will be allowed to operate a motor vehicle while conducting Department business.
Signature: Date:
LEIN Completed By: Name: Date:
LEIN Cleared: Yes No (Does not apply to Human Resources)
MDOC Employment/HR purposes: Indicate the # of convictions:
Comment (Optional):
hallt2 Text Box Facility/Project Name: Kinross Correctional Facility - Buffer Fence & Entrance Gate File # 472/25259.ABG
File details come from the government source that posted it. Updated .